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Florida State University Libraries Electronic Theses, Treatises and Dissertations The Graduate School 2004 Psychiatric Patients' Perception of Music Therapy Activity Relevance to Community Life Skills Kelli M. Nall Follow this and additional works at the FSU Digital Library. For more information, please contact lib-ir@fsu.edu

THE FLORIDA STATE UNIVERSITY SCHOOL OF MUSIC PSYCHIATRIC PATIENTS PERCEPTION OF MUSIC THERAPY ACTIVITY RELEVANCE TO COMMUNITY LIFE SKILLS By KELLI M. NALL A Thesis submitted to the School of Music in partial fulfillment of the requirements for the degree of Master of Music Degree Awarded: Summer Semester, 2004

The members of the Committee approve the Thesis of Kelli M. Nall defended on June 9, 2004. Jayne Standley Professor Directing Thesis Clifford Madsen Committee Member Diane Gregory Committee Member Approved: Jayne Standley, Chair, Music Therapy Jon R. Piersol, Dean, School of Music The Office of Graduate Studies has verified and approved the above named committee members. ii

TABLE OF CONTENTS List of Tables... iv List of Figures... v Abstract... vi I. Literature Review... 1 Psychiatric Rehabilitation... 1 Psychiatric Patients and Perception... 2 Research Involving Psychiatric Patients and Perception... 3 Music Therapy and Mental Illness... 5 Music Therapy Curriculum in the Treatment of Mental Illness... 5 Research Involving Music Therapy Techniques and Mental Illness... 6 Use of Musical Instruments in Music Therapy... 10 Curriculum in the Use of Musical Instruments in Music Therapy... 10 Research Involving Musical Instruments and Achievement of Life Skills 11 II. Method... 14 Participants... 14 Design... 14 Procedures... 14 Sessions... 15 III. Results.... 18 IV. Discussion... 21 APPENDICES A Life Skills Questionnaire... 24 B Madsen & Madsen Behavioral Observation Form for On/Off Task Behavior 25 iii

C Consent Form... 26 D Human Subjects Approval Letter... 27 E Lyrics for Amazing... 28 F Lyrics for I m Movin On... 29 G Lyrics for Beautiful... 30 H Lyrics for The Dance... 31 REFERENCES... 32 BIOGRAPHICAL SKETCH... 36 iv

LIST OF TABLES Table 1: Table of Demographics... 14 Table 2: Results of One-way ANOVA... 18 Table 3: Results of Two-way ANOVA... 18 v

LIST OF FIGURES Figure 1: Mean of Relevance Questionnaire Scores Across Time... 19 Figure 2: Group Percentage of On-task Behavior... 20 vi

ABSTRACT The purpose of this study was to assess psychiatric patients perception of music therapy activity relevance to community life skills versus on-task behavior as an indicator of daily functioning ability. The subjects consisted of nine clients, five females and four males. Those who agreed to participate in the study were diagnosed mainly with various forms of Schizophrenia or Schizoaffective disorders; subjects ranged from ages 31 to 64. The subjects attended eight total sessions: four lyric analysis discussions, and four performance activity sessions. At the conclusion of each session, subjects completed a questionnaire, created by the researcher, concerning their feelings on the relevance of the activity to community life skills. Each session two observers recorded on-task data using the Behavioral Observation Form (Madsen & Madsen, 1998). A One-way ANOVA indicated no significant difference. A Twoway ANOVA demonstrated no significant difference between either the lyric analysis session or the performance activity session. There was no significant difference in the on-task behavior of the subjects across time or between the two types of sessions. vii

CHAPTER I LITERATURE REVIEW In 1998, the National Institute of Mental Health estimated that approximately 44.3 million people in America suffer from a diagnosable mental disorder (Health, 2001). In shortterm psychiatric care, group as opposed to individual therapy appears to be the more costeffective form of treatment. The ultimate goal of short-term treatment in a psychiatric facility is to assist the client in returning to the community; this goal can be accomplished by aiding the client in learning daily life skills needed for the society in which he/she lives. (Wolfe, 2000) Group therapy should use techniques that reduce anxiety and assure the members that the group is a safe environment; therapists should initiate, facilitate, and encourage communication. Lastly, group therapy should support, reinforce, and validate the non-psychotic aspects of the patients behavior. (Maves & Schultz, 1985) Music therapists have noted successful behavior changes for both adult and adolescent psychiatric patients (de l'etoile, 2002). By using techniques such as improvisation, song writing, musical games, dance movement, and group performance, therapists can assist clients in achieving goals that may be difficult to achieve in other forms of therapy. (Fulford, 2002) Although antipsychotic medication efficiently reduces the most common symptoms of mental illness, individuals with mental illness often perform daily life skills inadequately (Wallace, 1993). Communications/relationships, assertiveness training, rational-emotive therapy, physical fitness, purpose-in-life, and vocational development are all life skills which are necessary to function in society and can be achieved in a relatively short period of time (Powell, 1985). Psychiatric Rehabilitation In addition to medication, psychiatric rehabilitation is the most promising treatment for patients suffering from a psychiatric disorder. The rationale for psychiatric rehabilitation lies in awareness that illness produces impairments, which reduces an individual s ability to perform 1

basic life skills. The impairments of a client with a mental illness clearly limit the individual s abilities to perform life skills and function in society. Rehabilitation, however, teaches these individuals to perform basic life skills using methods that make up for their impairment and modify the environment so that the new methods are successful or the skills are no longer required. (Wallace, 1993) In an article discussing the philosophy of the psychiatric rehabilitation approach, Anthony, Cohen, and Cohen (1983) explain that the goal of psychiatric rehabilitation is to assure that the person with a mental disability has the physical, emotional, and intellectual skills needed to live, learn, and work in his or her own environment. Similar to physical rehabilitation, psychiatric rehabilitation should focus on diagnosing and building on the client s already established skills. Psychiatric clients can learn a variety of physical, emotional, and intellectual skills regardless of their symptoms. When these skills are properly established in a comprehensive rehabilitation program with opportunity for their use and support in the community, there is significant impact on the outcome of the rehabilitation. Stromwall and Hurdle (2003)explain that creative treatment and vocational programs designed to promote recovery and using the principles of psychiatric rehabilitation help people with mental illness to develop meaningful relationships, maintain steady employment, and live successfully in the community. Principles of psychiatric rehabilitation include empowerment, competence, and recovery. Empowerment encourages clients to actively manage their symptoms, to make choices about the development and implementation of their treatment, and to develop a positive sense of self. Competence focuses on strengths, enhancing talents, and skills. Recovery is used to describe the desired outcome of the treatment and rehabilitation of the mental illness. Though research has shown the positive effects of psychiatric rehabilitation and mental illness, there is still a need for research in order to make rehabilitation more effective. (Wallace, 1993) Psychiatric Patients and Perception In a study examining group therapy versus individual counseling, Panas, Caspi, Fournier and McCarty (2003) found that group rather than individual therapy proved to be more productive. Subjects who participated in group therapy were more likely to achieve their desired treatment goals. Although group work appears to be an important approach to the facilitation of recovery it may not be apparent which group intervention activities actually contribute to the 2

recovery (Panas et al., 2003; Washington & Moxley, 2003). There appears to be little research involving psychiatric patients perceptions of the effectiveness of treatment interventions. Lemmens, Wauters, Heirman, Eisler, Leitaer and Sabbe (2003) suggest that therapists and practitioners be more aware of how the therapeutic process is experienced by families and clients and the meaning that they attach to these experiences. Thaut (1989) suggests that very little effort has been made to determine what specific intervention patients are responding and how different musical experiences can be made relevant to therapy. Washington and Moxley (2003) urge practitioners and therapists to examine intervention activities and understand the types of group work that participants find useful and effective in achieving their treatment goals. Research Involving Psychiatric Patients and Perception Lemmens, Wauters, Heirman, Eisler, Leitaer and Sabbe (2003) conducted a pilot study of the perception of helpful events by the therapeutic team and their families in two family discussion groups at a psychiatric day clinic. All participants, therapists, family members, and observers filled in questionnaires measuring helpful events for the individual, for the family, and for the group following each discussion. Results demonstrated that the therapeutic team and the families differed in their overall perception of which factors were important in family discussion group therapy. Family members more frequently mentioned aspects of the group such as experiencing communality and gaining insight whereas the therapeutic team was more likely to find group involvement and specific therapeutic interventions as the most helpful to the group. Graham, Friedman, and Paolino (1974) investigated the relationship between various aspects of the hospital treatment setting as well as treatment effectiveness. The hospital program in which the study was conducted included recreation programs, social discussion groups, rehabilitation counseling, and group therapy. Patients were asked to give their perceptions of the hospital setting regarding inaccessible staff, involvement of ward management, interesting and active settings, the involvement of staff, and expectation of patient responsibility. Results suggested that patients who experienced a reduction in thinking disturbances also showed higher scores on their perception of the interesting and active activities at the hospital. However, researchers conclude that when designing therapeutic interventions, practitioners should be careful not to equate patient satisfaction with therapeutic effectiveness. Thaut (1989) attempted to measure self-perceived changes in state of relaxation, emotion/mood, and insight in psychiatric prisoner-patients before and after music therapy 3

interventions. Patients completed a survey in which they were asked to state the most important experience they perceived as beneficial from a previous music therapy session. Based on these responses, self-report scales were designed to reflect the three most frequent response categories: mood, relaxation, and insight. Before leaving for and after returning from music therapy, clients were asked to rate themselves on each scale. At the conclusion of the study, all three self-report scales showed significant improvement in regard to music therapy and relaxation, mood, and insight. Thaut concluded that music therapy appears to have the strongest impact on selfperceived relaxation states, followed by mood and insight. Heaney (1992) investigated adult psychiatric patients evaluation of music therapy and other aspects of their overall treatment. Subjects rated music therapy, art therapy, recreation therapy, traditional therapies, and general aspects of care provided during hospitalization. Patients used a semantic differential to evaluate their treatment consisting of ten items, therapies or aspects of treatment, to be rated with the same four pairs of contrasting adjectives beneath each of them. Adjective pairs used included good/bad, important/unimportant, pleasurable/painful, and successful/unsuccessful. In addition, the subjects estimated the number of hours they spent in each aspect of treatment during their current hospitalizations. Results showed that music therapy was rated significantly higher than art and recreation therapy on the pleasurable/painful scale. De l Etoile (de l'etoile, 2002) examined the effectiveness of music therapy in short-term psychotherapy for adults with chronic mental illness. Subjects participated in one hour music therapy sessions, once a week, for six weeks; participants completed a 90-item clinical rating scale three times throughout the six week treatment. In addition to the clinical rating scale, clients completed a 5-point Likert-type scale, which rated the helpfulness of music therapy to 10 factors such as insight, self-disclosure, and altruism; the questionnaire was administered at the completion of the first and last music therapy session. De l Etoile concluded that music therapy might be perceived by the psychiatric patients as helpful, especially for the facilitation of group cohesion; music therapy may also improve attitudes toward help seeking. 4

Music Therapy and Mental Illness Music therapists have noted successful behavior changes for both adult and adolescent psychiatric patients (Carey & Halle, 2002; Sullivan, 2003; Waldon, 2001). Because of music s ability to influence thinking and emotional patterns, there is a greater potential for music therapy to promote mental health (de l'etoile, 2002). Music has the capacity to mirror the ambiguous and dynamic nature of human emotions (Goldberg, 1989). Music therapy also has the ability to provide motivation for clients who initially are not motivated (Rubin, 1973). Using techniques such as improvisation, song writing, musical games, dance movement, and group performance, therapists can assist clients in achieving goals that may be difficult to achieve in other forms of therapy (Fulford, 2002). Using the previously mentioned techniques, music therapy may specifically promote positive expression of feelings and emotions, improve self-awareness and self esteem, facilitate positive group interaction, and improve self-esteem (James & Townsley, 1989). Music Therapy Curriculum in the Treatment of Mental Illness When working with mentally disordered offenders, Reed (2002) found, among other activities, music listening to be effective in improving tolerance and respect of others, increasing positive use of leisure time, and improving self-esteem. The researcher also formed a gospel choir for the clients, which addressed the goals of socialization skills, self-expression, selfesteem, and task mastery. Reed concluded that many positive results have occurred in the realm of psychological rehabilitation through the use of music therapy activities such as singing, improvisation, and listening, however improvements are still needed in the cognitive, psychological, behavioral, and social functioning of the clients. Sullivan (2003) found that group singing can increase a sense of connection with peers, decreased impulsivity, increased attention span, and tolerance of others. The experience of singing with others also fosters an activity associated with normal life, thus promoting hope, expectation, and eventual return to the outside world. MacIntosh (2003) explained that group cohesiveness was solidified through the use of improvisational song writing techniques. Song writing offers a structured, safe, and flexible opportunity for the client to develop the ability to express thoughts and feelings and to receive peer approval in a confidential environment. Fill-in-the-blank techniques, vocal improvisation, and changing the words to familiar songs are some of the techniques used in music therapy. 5

Longhofer and Floersch (1993) found that forming a performing drum ensemble at two Kansas City metropolitan mental health centers was effective in assisting psychiatric patients with achieving goals such as a sense of competency, forming a sense of group identity, and strengthening the client s realization to make contributions to society. Research Involving Music Therapy Techniques and Mental Illness Anshel and Kipper (1988) investigated the effects of two components of group singing, music and activity, on trust and cooperation. Trust and cooperation were measured using the Griffin-Trust Differential (trust) and the Prisoner s Dilemma game (cooperation). Four groups of Israeli adult males participated in a single session of either group singing, listening to music, poetry reading, and film viewing. Results concluded that group singing had the greatest trust and cooperation scores, supporting the clinical application of group singing as a therapeutic intervention. Hilliard (2001) examined the effects of cognitive-behavioral music therapy in the treatment of women with eating disorders. Music served to motivate patients as they engaged in the process of recovery and enhanced their positive affect about the process. Techniques used included song writing, singing, drumming, and lyric analysis discussion. Through personal observation and the observations of the staff at the Renfrew Center of Florida, the researcher concluded that cognitive-behavioral music therapy appears to have a positive effect when working with clients with eating disorders. Henderson (1983) studied the effects of a music therapy program on the awareness of mood in music, group cohesion, and self-esteem among hospitalized adolescent patients; subjects had the diagnosis of adjustment reaction to adolescence. Subjects in the control group did not attend music therapy; experimental subjects participated in group discussions concerning moods and emotions in music, expression and identification of body language, story composition to recorded music, and drawing to music. Henderson administered four types of pre and posttests including agreement on mood or emotion expressed in music as measured by an adjective checklist, sociograms to measure group cohesion, the number of pronouns expressing group feelings, and scores of the Coopersmith Self-Esteem Inventory. The results showed significant increases between pre and posttest scores for the experimental subjects on exact choices of adjectives to be used to describe recorded compositions as well as on the number of pronouns 6

used to describe group feeling. The experimental group improved more than did the control group and significance was improved for the group cohesion measure. Kivland (1986) examined the effect of individual music therapy sessions on self-esteem in an adolescent boy with a diagnosis of conduct disorder. Self-esteem was measured by frequency of both positive and negative self-statements and by the ability to accept positive comments appropriately. Music therapy sessions consisted of activities covering music therapy, note reading, ear training, and self-expression. During the 12-week treatment period, the frequency of spontaneous negative self-comments decreased. Although the frequency of positive self-statements did not increase, the number of prompted ones did increase. At the conclusion of treatment, the subject was able to list independently what he had done well at each session, and was able to accept positive comments from others appropriately. Gold, Wigram, and Berger (2001) conducted a pilot study to determine the effects of individual music therapy with mentally ill children and adolescents on symptoms, competencies, and quality of life. Subjects were referred to out-patient individual music therapy in various institutions. Prior to the start of music therapy, the therapist described the reason for the client s referral, the aims of music therapy, and session duration and frequency. At the conclusion of therapy, the therapist reported the content and success of therapy, including what interventions were most successful. Musical interventions that were reported as helpful included musical mirroring and partner improvisation. The results of the study showed that music therapy had a greater effect on the symptoms and competencies of the subjects than on quality of life. A study analyzing the effect of background music on the task performance of psychotic children was conducted by Burleson, Center, and Reeves (1989). Subjects were provided with a color-coded sorting task and given verbal instructions to begin the task. Subjects were to place the colored chips in the corresponding colored container. The experimental group received instrumental music without a strong rhythmic beat played during the intervention period of the study. Results indicated a significant effect for background music on task performance. Williams and Dorow (1983) examined the effect of a music therapy treatment on the number of complaints and non-complaints emitted by a chronically depressed psychiatric patient. The researchers compared no-music listening with verbal sympathy after complaints and praise for non-complaints, interrupted music listening with verbal reprimands after complaints and praise for non-complaints, and interrupted music listening only for complaints with no verbal 7

feedback for complaints or non-complaints. Using an ABACA design, data was taken on the number of complaints and non-complaints emitted by the patient. The results showed a decrease in complaints and an increase in non-complaints during the interrupted music phases. During the final no-music phase, the level of complaints remained lower than earlier baseline phases indicating that the entire treatment had an effect on the number of complaints emitted by the subject. Hauck and Martin (1970) examined the effect of music as a reinforcer for a 59-year-old patient who had been hospitalized for ten years with a diagnosis of schizophrenia undifferentiated. The client demonstrated inappropriate mannerisms such as pacing back and forth, rocking back and forth when seated, and finger flicking. Therapy sessions were divided into two ten-minute sessions. The first segment was a non-contingent period in which no relationship was programmed between the subjects mannerisms and music. Contingencies were made during the second ten-minute segment. Emission of any of the inappropriate mannerisms caused immediate cessation of music; subsequent termination of the response resulted in immediate resumption of the music presentation. Data was gathered by an assistant who recorded the amount of time that the subject spent emitting each in appropriate behavior. Results concluded that the contingency arrangements produced an evident reduction in response duration. According to ward staff reports, effects of the treatment also appeared to have influenced the subject s behavior outside of music therapy. Silverman (2002) described music therapy as an effective tool in treating mental illness in both long and short-term facilities. In a case study involving a combative client diagnosed with schizophrenia, Silverman used contingency songwriting to reduce unwanted behavior in the subject. By implementing a songwriting contingency program, the music therapist was able to transfer the client s appropriate behavior in music therapy groups to behavior on the unit. Silverman concluded that it was the sum of the entire music therapy treatment process that built a strong rapport between the music therapist and the client; it was through this rapport that the client began to demonstrate appropriate behavior. Hodgson (1996) examined the effects of music therapy on the attendance rate and number of verbal prompts given to elicit attendance of adult psychiatric clients in a day treatment center. Pretest data were collected for attendance and number of verbal prompts given in order to elicit attendance in program activities. Interventions used included group singing, music 8

listening, lyric analysis, instrumental improvisation, and group/individual song writing. Although no there was no statistical significance in the difference of scores of attendance or number of verbal prompts given, 60% of the subjects did have lower posttest scores for the number of verbal prompts given. Glicksohn and Cohen (2000) investigated whether music would have a positive effect on the cognitive task performance of schizophrenics. Subjects were tested using the Stroop task, an activity in which the participant is asked to name the color of a printed word. Following completion of the activity, subjects were asked to estimate the time spent on the task. Each Stroop task was completed four times, twice while listening to music, and twice in silence. The results demonstrated that the music condition improved task performance. Researchers concluded that music appears to have had a relaxing effect on the schizophrenics. Cassity (1976) conducted a study to determine if participation in a valued group musical activity, such as group guitar lessons, enhanced interpersonal relationships to a significantly greater degree than participation in non-music activities when working with adult female psychiatric patients. Interpersonal relationships were compared by measuring changes in peer acceptance, group cohesiveness, and general interpersonal relationships occurring between sociometric pre and posttests. The results demonstrated that the experimental group made significant gains in peer acceptance and group cohesiveness. Tang, Yao, and Zheng conducted a study to determine the rehabilitative effect of music therapy for residual schizophrenia. Seventy-six patients who had the residual type of schizophrenia were randomly assigned to a treatment group or a control group. The treatment group received a one-month course of music therapy that included both passive listening and active participation in the singing of popular songs with other patients. The outcome of the treatment was evaluated by four nurses using Chinese versions of the Scale for Assessment of Negative Symptoms and the in-patient version of the World Health Organization s Disability Assessment Scale. Music therapy significantly diminished the subjects negative symptoms and increased their ability to converse with others. Treatment also reduced their isolation and increased their interest in external events. 9

Use of Musical Instruments in Music Therapy Music therapists often use various instruments and musical ensembles to help their clients achieve desired goals (Cevasco & Grant, 2003; Confrancesco, 1985; Moreno, 1985; Stith, 1965; Wylie, 1996). Using instrumentation and musical ensembles, the therapist addresses goals such as teaching clients to stay on task, learning appropriate social behavior, and following directions (Diraimondo, 2002). Musical instruments can also be used in music therapy to address issues such as communication skills, personal insight, and emotional understanding (Rolvsjord, 2001). Curriculum in the Use of Musical Instruments in Music Therapy MacIntosh (2003) describes toning as a music therapy technique effective in working with survivors of sexual abuse. Toning involves the intense and focused singing of a single pitch on a vowel sound. The process assists the client in staying grounded and self-aware even when participating in emotionally difficult exercises. MacIntosh explained that toning creates safety, empowerment, and containment in a group environment Winkelman (2003) described drumming activities as a treatment for addiction. Drumming produces pleasurable experiences, induces relaxation, enhances awareness and preconscious dynamics, release of emotional trauma, and reintegration of self. Drumming also alleviates self-centeredness, isolation, and alienation, creating a sense of cohesiveness with self and others. Watson (2002) developed a music therapy drumming and improvisation treatment component for residential adult male sexual offenders. Goals to be met included social skills, intimacy, pro-social behavior, and awareness and expression of emotions. The purpose of the group was to use drumming and group musical improvisation to provide opportunities for nonverbal self-expression, positive group/social experiences, leadership opportunities, cooperation, and a safe environment to release intense emotions. Group sessions occurred one hour weekly for one year. The format of each session included a warm-up/focussing activity, free improvisation, and a closing task. When working with mental illness, Stith (1965) emphasized the importance of assisting the client in making a transition from the hospital back into the community as well as helping the client to achieve a better state of emotional health. Among other activities, Stith suggests having musical instruments such as guitars, drums, autoharps, a piano, or clarinet available to the clients who wish to play in their spare time to facilitate the growth of positive leisure skills. 10

Research Involving Musical Instruments and Achievement of Life Skills Cevasco and Grant (2003) compared responses to vocal versus instrumental music during exercise with instruments with Alzheimer s patients. Four conditions were compared throughout the study. Exercise to both vocal and instrumental music, and exercise to both vocal and instrumental music with instruments. Researchers collected data by recording the participation of each client for the duration of each exercise-to-music activity. Instrumental music resulted in more participation than vocal music. Exercise with instruments and instrumental music resulted in more participation than did exercise with instruments to vocal music. Cook and Freethy (1973) conducted a case study in which hymn playing was used to reduce complaining behaviors of a 43-year old woman diagnosed as mildly retarded, undifferentiated schizophrenic. Researchers observed the client during two half-hour sessions each week, taking data on the frequency of the client s complaining behavior. Hymn playing was chosen as a reinforcer during the treatment sessions, contingent upon the presence of the complaining behavior. The results of the study concluded that music, when used as a contingency, was an effective reinforcer in eliminating the complaining behavior of this client. In a study comparing the effects of active versus passive group music therapy on preadolescents, Montello and Coons (1998) used percussion instruments and music listening to reduce the symptoms of emotional, learning, and behavioral disorders. Active music therapy consisted of reproducing a rhythm modeled by the therapist, repeating the same rhythm continuously, and solo improvisation. During passive music therapy, subjects listened to various kinds of music and were encouraged to discuss and share their responses to the music. Researchers used Achenbach s Teacher Report Form to confirm changes among the subjects in attention, motivation, and hostility as rated by homeroom teachers. Results indicated that subjects improved significantly after receiving both music therapy interventions, most notable change was in found on the aggression/hostility scale. In a case study involving a hospitalized adolescent female diagnosed with an unstable personality disorder, impulsive type, and non-suicidal self-harm, Rolvsjord (2001) focused on how the process of learning musical skills, such as piano, can initiate therapeutic objectives concerning grief and relationships. As the client learned to play piano, she was able to work through her feelings and difficult experiences. Through personal observation, Rolvsjord 11

concluded that learning piano initiated motivation for therapy and functioned as a secure base, which allowed the adolescent to explore her dramatic experiences and inner feelings. Sullivan (2003) conducted a study that combined music therapy with psychoanalytic concepts of free association. By organizing a community sing, the researcher explained that she would address the whole person, physically, neurologically, emotionally, and psychologically. The researcher prepared a weekly community sing by assembling a large group of songs, in an effort to stimulate memories and feelings for a variety of clients. Through personal observation, Sullivan concluded that the community sing can increase a sense of connection with peers, decreased impulsivity, increased attention span, and tolerance of others. The experience of singing with others also fosters an activity associated with normal life, thus promoting hope, expectation, and eventual return to the outside world. Pavlicevic, Trevarthen, and Duncan (1994) investigated the effects of improvisational music therapy and the rehabilitation of schizophrenic patients. After completing an initial assessment with the therapist involving free improvisation using various percussion instruments. Clients were ranked on the Music Interaction Rating for Schizophrenia scale, created by the researcher; the scale is comprised of six levels of musical engagement between the therapist and the client. Subjects also completed items selected from Luria s Neuropsychological Investigations, measuring the subjects perception and reproduction of pitch relationships, rhythmic patters, number of beats, and the use of accents. The treatment group received nine weeks of individual music therapy sessions with the therapist using improvisation on musical instruments. The control group received no music therapy or substitute activity. Both groups attended the final session, which followed the same format as the first session had. Subjects who participated in the treatment group show a statistically significant improvement in their clinical state as measured by the Brief Psychiatric Rating Scale when compared to the control group. The treatment group also showed an increase in their length of musical interaction by the end of the ten sessions. In a study using African drumming to address psychiatric rehabilitation, Longhofer and Floersch (1993) established a performing drum ensemble at two Kansas City metropolitan mental health centers. Researchers argued that participation in a musical ensemble would lead to outcomes that complemented psychiatric rehabilitation by improving the client s sense of competency, forming a sense of group identity, and strengthening the client s realization to make 12

contributions to society. Longhofer and Floersch applied group process techniques to facilitate social skills development, group cohesion, and decision-making abilities. The nature of participating in a drumming ensemble allowed subjects the opportunity to occupy a productive and satisfying position, as a drummer, within a larger group from which the nature of mental illness often excludes them. Using the observations of mental health staff, researchers concluded that the project had a positive effect on the clients by increasing their self-esteem, building a supportive peer group, and fostering skill development. The purpose of this study is to assess psychiatric patients perception of music therapy activity relevance to community life skills versus on-task behavior as an indicator of daily functioning ability. It is hypothesized that psychiatric patients will perceive both the lyric analysis and tone chime sessions to be effective in assisting them with development of life skills. It is further hypothesized that clients will be more on-task to tone chime sessions rather than the lyric analyses. 13

CHAPTER II METHOD Participants Subjects were clients in the existing music therapy program at the Hilltop Residential Treatment Center. Participants included nine clients, five females and four males. Those who agreed to participate in the study suffered from either Schizophrenia or Schizoaffective disorders; subjects ranged from ages 31 to 64. Table 1: Table of Demographics Subject # Age Sex Diagnosis 1 61 Female Schizophrenia Disorganized 2 61 Female Psychotic Disorder NOS/Mild Mental Retardation 3 63 Female Schizophrenia, Paranoid Type 4 59 Female Schizoaffective Disorder 5 45 Male Schizoaffective Disorder, Bipolar Type 6 64 Male Schizoaffective Disorder 7 47 Male Schizophrenia, Unidifferentiated 8 44 Female Schizoaffective Disorder 9 31 Male Schizophrenia, Unidifferentiated *NOS denotes Not Otherwise Specified Design Subjects served as their own control across a changing condition design of ABABABABAB where A= discussion activity and B= performance activity. The dependent variables were self-report rating of relevance of the activity and observation of on-task behavior. Procedures Twice a week, the residents participated in two different types of music activities, a lyric analysis discussion and a tone chime performance ensemble; each session lasted forty-five 14

minutes each. This process continued for four weeks. Following each session, the subjects were asked to fill out a questionnaire, created by the researcher, concerning their feelings on the relevance of the activity to community life skills (Appendix A). The questionnaire asked clients to rate the relevance of the activity to each of ten listed life skills on a 5-point Likert-type scale. In addition to the life skills questionnaire, each session two observers recorded data on on-task behavior of the subjects using the Madsen & Madsen Behavioral Observation Form for On/Off Task Behavior (Appendix B) (1998). The observers were trained and instructed on what defined on and off-task behavior during sessions. Reliability was computed for all sessions and averaged.96 for each session. Operant definitions were set for on and off-task behavior for both the lyric analysis sessions and tone chime sessions. A prerecorded tape asked observers to observe for on/off-task behavior for thirty seconds and record for five seconds; recording took place for 30 minutes of each session. During a lyric analysis session, clients were considered on-task if they were listening and responding to the therapist when appropriate. In order to be on-task during a lyric analysis, the client had to appear to be paying attention and focused on the therapist or another group member who was speaking. In order for a client to be considered on-task for a tone chime session, the client needed to attempt to play the tone chime properly and respond to the therapist when appropriate. The client also needed to appear to be paying attention to the therapist and the music. Guidelines for off-task for both groups were much the same. Clients who made any interruption in the group, either verbal or motor, were considered off-task. Verbal behaviors that were considered off-task included: yelling, blurting out, whistling, humming, screaming, singing and laughing at inappropriate times. Motor behaviors that were considered off-task included: getting out of one s seat, running, walking around the room, waving arms, kicking, pushing, hitting, grabbing, and throwing. Other behaviors considered off-task during both sessions included daydreaming, sleeping, and staring into space. Sessions Week 1 The clients participated in a lyric analysis of the song Amazing (Appendix C). The goals of the session focused on increasing decision-making skills, the awareness of others, the acceptance of responsibility, personal insight, and communication skills. Following the session, clients completed the life skills questionnaire. 15

In the second session of the week, clients were instructed on the proper usage of the tone chimes. Each resident was given one tone chime, each tone chime was color-coded and fit into either the tonic (blue), subdominant (green), or dominant (red) chords. Songs were written onto a large chart; above the word on which a chord progression change would occur, a colored square was drawn. Residents were instructed that they were to play any time the therapist pointed to their color. The clients were invited and encouraged to sing along with the therapist; songs played included, You Are My Sunshine, Lean On Me, Amazing Grace, and Blue Moon. Following the session, clients completed the life skills questionnaire. Week 2 Clients participated in a lyric analysis of the song Movin On (Appendix D). The goals of the session focused on increasing decision making skills, increasing the awareness of others, the acceptance of responsibility, personal insight, and communication skills. Following the session, clients completed the life skills questionnaire. During the second session of the week clients were arranged into groups and assigned a tone chime. The residents were invited and encouraged to sing along with the therapist; songs played included, Don t Worry Be Happy, My Girl, Red River Valley, and This Little Light of Mine. Following the session, clients completed the life skills questionnaire. Week 3 Clients participated in a lyric analysis of the song Beautiful (Appendix E). The goals of the session focused on decision making skills, positive aspects of their personal lives, and developing a positive attitude. Following the session, clients completed the life skills questionnaire. During the second session of the week clients were arranged into groups and assigned a tone chime. The residents were invited and encouraged to sing along with the therapist; songs played included, I ll Fly Away, Brown-eyed Girl, and Let It Be. Following the session, clients completed the life skills questionnaire. Week 4 Clients participated in a lyric analysis of the song The Dance (Appendix F). The goals of the session included increasing decision-making skills and awareness of consequences associated with taking chances, and promoting the acceptance of responsibility for actions. Following the session, clients completed the life skills questionnaire. 16

During the second session of the week clients were arranged into groups and assigned a tone chime. The residents were invited and encouraged to sing along with the therapist; songs played included, Jamaican Farewell, Up On the Roof, and Down By the Riverside. Following the session, clients completed the life skills questionnaire. 17

CHAPTER III RESULTS A One-way Analysis of Variance (ANOVA) with repeated measures was conducted on the eight sessions to determine if there was a significant difference across sessions due to time on the relevance questionnaire scores. The One-way ANOVA indicated no significance at F(7,56) = 1.13, p =.358. Table 2: Results of One-way ANOVA df Mean Squares F-value Siginificance Group 1 1.837 0.012 0.915 Error 16 156.629 A Two-way ANOVA with repeated measures was conducted to conclude if there was a significant difference between the lyric analysis sessions and the performance activity sessions on relevance questionnaire scores. Again, the two-way ANOVA showed no significant difference between the two types of sessions at F(3,48) = 1.55, p =.213. Table 3: Results of Two-way ANOVA df Mean Square F-value Siginificance Session 3 99.755 1.554 0.213 Group & Session 3 47.866 0.746 0.53 Error 48 64.175 Figure 1 shows mean relevance questionnaire scores across session by group. The researcher can identify no reason for the drop in scores in session three for the lyric analysis group. The overall mean score of the relevance questionnaires = 37.62. 18

42 40 38 36 Mean Scores 34 Group Lyric Analysis 32 1 2 3 4 Performance Activity Sessions Figure 1 Mean of Relevance Questionnaire Scores Across Time The on and off task behavior recorded by the observers was graphed in order to determine the effects of lyric analysis and performance activity over time (figure 2). Results indicated that the on-task behavior appeared to improve for both activities during the second and third sessions, however declined yet again during the final session. The overall mean score for on-task behavior = 55.38. 19

100 Percentage On-Task 50 0 1 2 3 4 Sessions Series1 Series2 Figure 2 Group Percentage of On-Task Behavior A Mann-Whitney U Test (Clifford K. Madsen & Moore, 1978) was performed to determine if there was a difference in the on-task behavior between the lyric analysis and performance activity sessions. The results indicated that there was no significant difference (obtained U = 5.0, critical U =.243, α >.05). 20

CHAPTER IV DISCUSSION The purpose of this study was to assess psychiatric patients perception of music therapy activity relevance to community life skills versus on-task behavior as an indicator of daily functioning ability. No significant difference between either the lyric analysis session or the performance activity session were found. In addition, there was no significant difference in the on-task behavior of the subjects across time or between the two types of sessions. Although no significant differences were found, subjects appeared to find both the lyric analysis and the performance activity sessions to be relevant to community life skills; this confirms the researcher s hypothesis. The wording used on the relevance questionnaire may have had some effect on the answers given by the subjects. Most likely due to a below average reading level, clients appeared to be confused by some of the wording on the questionnaire such as increasing your knowledge of resources and increasing your involvement in the community. The phrase, How relevant do you feel this activity was to? appeared to perplex a few of the subjects. Although much effort was made to make the wording of the questionnaire such that the subjects could understand it, future research should include alternative wording such as How helpful do you feel this activity was toward? The initial session yielded a low mean in the on-task behavior of the subjects. During this initial session, one of the subjects appeared to be sleeping as a result of a change in medication. Although medication is necessary in the treatment of mental illness, it can have a negative impact on the collection of data. Researchers should take into account that the subjects which they are studying may be undergoing medication or diet changes which impact their behavior, thus effecting the collection of accurate data. The on-task behavior of the subjects improved for both the second and third sessions, declining at the conclusion of the study. These improvements may be the result of medication changes and adaptations in the subjects. Other factors contributing to the change may include building rapport with the therapist and other group members or developing a sense of comfort 21

with participating in the research study. Though on-task behavior appeared to improve throughout the study, the results still do not support the hypothesis that clients will be more ontask to performance activity sessions rather than the lyric analyses. During the third week of data collection, the facility acquired three to four new members who did not participate in the study. In addition, one of the subjects was temporarily hospitalized in order to adjust medication. It was during this transitional period that there was a decline in the on-task behavior and relevance questionnaire scores. Although the new members did not participate in the study and were not accounted for in the on-task behavior observations, it is possible that their initial presence had some effect on the behavior and attitudes of the subjects. It is the nature of psychiatric populations for clients to be discharged and admitted frequently. These recurrent changes, even in a residential setting, can effect the attitudes and behaviors of its clients, thus having a possible effect on the research study. Another concern in the collection of data in this particular study is the researcher s relationship with the subjects. Over the course of data collection, the subjects appeared to become quite attached to the researcher, frequently offering compliments and positive remarks. Though it is part of the therapist s job to build a sense of rapport with the clients, it can hinder the results of the study. Because the clients grew fond of the researcher as time passed, it is possible that they chose to increase their scores on the relevance questionnaire thus effecting the overall data. During the final session, the researcher offered a token of the thanks to the subjects by bringing various food items to be consumed at the conclusion of the group. During this time, subjects were allowed to express their concerns and any questions they might have. The participants reported how much they had enjoyed having the researcher each week to conduct music therapy. Although no significant data was reported in the present study, subjects reportedly enjoyed both the lyric analyses and performance activity sessions and found them to be equally helpful. It is recommended that future research involving psychiatric patients perception of music therapy include more subjects and a longer time span. Including more participants in the study for a longer period of time would increase the likelihood for a preference to be made for a particular type of session. In addition, extending the data collection period and increasing the number of subjects may have an effect on the overall on-task behavior of the group. Future 22

research should also examine other music therapy techniques such as song writing or music relaxation. 23

APPENDIX A Life Skills Questionnaire Subject ID #: Date: Please rate the following on a scale of 1 5, 1 meaning very little and 5 meaning quite a bit. How relevant do you feel this activity was to : communicating with others in the community 1 2 3 4 5 developing job skills to be used in the community 1 2 3 4 5 adjusting to new situations 1 2 3 4 5 coping with the stress of daily life 1 2 3 4 5 increasing your involvement in the community 1 2 3 4 5 increasing your self-esteem 1 2 3 4 5 increasing your level of self-control 1 2 3 4 5 increasing acceptance of responsibility for your actions 1 2 3 4 5 increasing leadership skills to be used in the community 1 2 3 4 5 increasing your knowledge of resources in the community 1 2 3 4 5 24

APPENDIX B Madsen & Madsen Behavioral Observation Form for On/Off Task Behavior 25

APPENDIX C Consent Form Psychiatric patients perception of music therapy activity relevance to community life skills Participant Consent Form Ms. Kelli Nall, who is a graduate student at Florida State University, has requested my participation in a research study as part of her degree requirements. The purpose of the research is to determine if psychiatric patients perceive a lyric discussion or a performance ensemble to be more relevant to developing the community life skills necessary for discharge. My participation will involve taking part in music therapy twice a week for four weeks, a total of eight, 45 minute sessions. The research will involve participating in a lyric discussion and a music ensemble each week in which I will learn to play the tone chimes. At the conclusion of four weeks, the music group will perform for the residential staff. Possible benefits of your participation in this research study include an increase in daily life skills such as communication, self-awareness, self-esteem, and coping skills. Another possible benefit to my participation in the research study is learning to play a musical instrument and the rewards of performing in a musical ensemble. I understand that there are no predictable risks or discomforts if I agree to participate in the study. I understand that the therapist will not have access to my files at any time and my name or identity will not be used, in any way, in her written thesis. If I have any questions concerning the research study or my participation in it, I can arrange a meeting with Ms. Nall through Mrs. Plank; I can also contact her faculty advisor, Jayne Standley, at 850-644-4565. If I have questions about my rights as a participant in this research, or if I feel I have been placed at risk, I can contact the Chair of the Human Subjects Committee, Institutional Review Board, through the Office of the Vice President for Research, at (850) 644-8633. The conditions, benefits, and any risk of the project have been explained to me; I intentionally accept any risks involved. I have read the above informed consent form. I understand that I am not required to participate in this study and that I may stop participation at any time without compromising my access to the services of Apalachee Center. By signing this consent form, I am not giving up any legal privileges, rights or treatments. A copy of this consent form will be given to me. Subject's Signature (Date) Apalachee Staff Witness (Date) 26

APPENDIX D Human Subjects Approval Letter 27